Endovascular treatment of a direct post-traumatic carotid-cavernous fistula with electrolytically detachable coils

Abstract

Carotid-cavernous fistulae are abnormal communications between the internal carotid artery and venous compartments of the cavernous sinus. Fistulae are uncommon but well-documented sequelae of craniofacial trauma. The characteristic clinical presentation includes ocular pain, chemosis, exophthalmus and visual disturbances. We report on a 28-year-old man with a history of severe craniocerebral injury, including multiple craniofacial fractures resulting from a fall from a height of approximately 6 meters, who was surgically treated one year ago. Two months before presentation, the patient began to exhibit progressive chemosis, proptosis, eyelid swelling, diplopia and exophthalmus. Computerized tomography and computerized tomographic angiography revealed findings consistent with a carotid-cavernous fistula of the right side of the cavernous sinus with dilatation of the right ocular vein. Digital subtractional angiography of the right internal carotid artery revealed a fistula between the cavernous part of the artery and the right cavernous sinus. There was only minimal blood flow in the supraclinoid part of the internal carotid artery because of the high pressure within the fistula. Our decision was to try to occlude the fistula by means of endovascular embolization. The origin of the fistula in the internal carotid artery was successfully obliterated with seven electolytically detachable coils. Control digital subtractional angiography at the end of the procedure demonstrated minimal residual flow through the fistula. Two months after the treatment, angiographic control revealed complete obliteration of the fistula. Clinical examination showed total resolution of signs and symptoms of a carotid-cavernous fistula. Endovascular transarterial embolization of carotid cavernous fistulae is a widely accepted, safe and successful treatment option. In the case that we describe we occluded the fistula and right cavernous sinus with electrolytically detachable coils that we could place into the sinus. Other endovascular treatment options include the use of detachable balloons, stent placement, transvenous embolization or surgical ligation of the fistula.